|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [14372]
|
Facility
|
IP
|
$40.84
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.67 |
| Max. Negotiated Rate |
$40.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.02
|
| Rate for Payer: Aetna of WY Medicare |
$26.14
|
| Rate for Payer: Altius Commercial |
$39.21
|
| Rate for Payer: Beech Street Commercial |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.61
|
| Rate for Payer: Cash Price |
$28.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.61
|
| Rate for Payer: Cigna of WY Commercial |
$40.02
|
| Rate for Payer: Entrust Commercial |
$38.80
|
| Rate for Payer: First Choice Health Commercial |
$38.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.91
|
| Rate for Payer: HealthUtah PPO |
$40.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.61
|
| Rate for Payer: Multiplan Medicare/VA |
$23.67
|
| Rate for Payer: One Health Plan of WY PPO |
$40.02
|
| Rate for Payer: PacificSource Commercial |
$36.76
|
| Rate for Payer: PHCS PPO |
$40.02
|
| Rate for Payer: Three Rivers PPO |
$30.63
|
| Rate for Payer: TriWest Veterans Administration |
$24.91
|
| Rate for Payer: United Healthcare Commercial |
$39.00
|
| Rate for Payer: United Healthcare Medicare |
$24.91
|
| Rate for Payer: WINHealth Partners Commercial |
$38.80
|
| Rate for Payer: Wise Provider Network Commercial |
$38.80
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [11179]
|
Facility
|
IP
|
$54.88
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.80 |
| Max. Negotiated Rate |
$54.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.78
|
| Rate for Payer: Aetna of WY Medicare |
$35.12
|
| Rate for Payer: Altius Commercial |
$52.68
|
| Rate for Payer: Beech Street Commercial |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.23
|
| Rate for Payer: Cash Price |
$38.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.23
|
| Rate for Payer: Cigna of WY Commercial |
$53.78
|
| Rate for Payer: Entrust Commercial |
$52.14
|
| Rate for Payer: First Choice Health Commercial |
$52.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.48
|
| Rate for Payer: HealthUtah PPO |
$54.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.23
|
| Rate for Payer: Multiplan Medicare/VA |
$31.80
|
| Rate for Payer: One Health Plan of WY PPO |
$53.78
|
| Rate for Payer: PacificSource Commercial |
$49.39
|
| Rate for Payer: PHCS PPO |
$53.78
|
| Rate for Payer: Three Rivers PPO |
$41.16
|
| Rate for Payer: TriWest Veterans Administration |
$33.48
|
| Rate for Payer: United Healthcare Commercial |
$52.41
|
| Rate for Payer: United Healthcare Medicare |
$33.48
|
| Rate for Payer: WINHealth Partners Commercial |
$52.14
|
| Rate for Payer: Wise Provider Network Commercial |
$52.14
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [11179]
|
Facility
|
OP
|
$54.88
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.72 |
| Max. Negotiated Rate |
$54.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.78
|
| Rate for Payer: Aetna of WY Medicare |
$36.22
|
| Rate for Payer: Altius Commercial |
$52.68
|
| Rate for Payer: Beech Street Commercial |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.23
|
| Rate for Payer: Cash Price |
$38.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.23
|
| Rate for Payer: Cigna of WY Commercial |
$53.78
|
| Rate for Payer: Entrust Commercial |
$52.14
|
| Rate for Payer: First Choice Health Commercial |
$52.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.28
|
| Rate for Payer: HealthUtah PPO |
$54.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.23
|
| Rate for Payer: Multiplan Medicare/VA |
$29.72
|
| Rate for Payer: One Health Plan of WY PPO |
$53.78
|
| Rate for Payer: PacificSource Commercial |
$49.39
|
| Rate for Payer: PHCS PPO |
$53.78
|
| Rate for Payer: Three Rivers PPO |
$41.16
|
| Rate for Payer: TriWest Veterans Administration |
$31.28
|
| Rate for Payer: United Healthcare Commercial |
$52.41
|
| Rate for Payer: United Healthcare Medicare |
$31.28
|
| Rate for Payer: WINHealth Partners Commercial |
$53.78
|
| Rate for Payer: Wise Provider Network Commercial |
$52.14
|
|
|
AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION
|
Professional
|
Both
|
$8,180.00
|
|
|
Service Code
|
HCPCS 27886
|
| Min. Negotiated Rate |
$524.98 |
| Max. Negotiated Rate |
$8,180.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,016.40
|
| Rate for Payer: Aetna of WY Medicare |
$617.62
|
| Rate for Payer: Beech Street Commercial |
$7,771.00
|
| Rate for Payer: Cash Price |
$5,726.00
|
| Rate for Payer: Cash Price |
$5,726.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,934.60
|
| Rate for Payer: Cigna of WY Commercial |
$8,016.40
|
| Rate for Payer: First Choice Health Commercial |
$7,362.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,771.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$617.62
|
| Rate for Payer: HealthUtah PPO |
$8,180.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,934.60
|
| Rate for Payer: Multiplan Medicare/VA |
$524.98
|
| Rate for Payer: One Health Plan of WY PPO |
$8,016.40
|
| Rate for Payer: PacificSource Commercial |
$7,362.00
|
| Rate for Payer: PHCS PPO |
$7,771.00
|
| Rate for Payer: Three Rivers PPO |
$6,135.00
|
| Rate for Payer: TriWest Veterans Administration |
$617.62
|
| Rate for Payer: United Healthcare Commercial |
$7,771.00
|
| Rate for Payer: WINHealth Partners Commercial |
$6,953.00
|
|
|
AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION
|
Professional
|
Both
|
$6,710.00
|
|
|
Service Code
|
HCPCS 27886 AS
|
| Min. Negotiated Rate |
$5,032.50 |
| Max. Negotiated Rate |
$6,710.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,575.80
|
| Rate for Payer: Beech Street Commercial |
$6,374.50
|
| Rate for Payer: Cash Price |
$4,697.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,508.70
|
| Rate for Payer: Cigna of WY Commercial |
$6,575.80
|
| Rate for Payer: First Choice Health Commercial |
$6,039.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,374.50
|
| Rate for Payer: HealthUtah PPO |
$6,710.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,508.70
|
| Rate for Payer: One Health Plan of WY PPO |
$6,575.80
|
| Rate for Payer: PacificSource Commercial |
$6,039.00
|
| Rate for Payer: PHCS PPO |
$6,374.50
|
| Rate for Payer: Three Rivers PPO |
$5,032.50
|
| Rate for Payer: United Healthcare Commercial |
$6,374.50
|
| Rate for Payer: WINHealth Partners Commercial |
$5,703.50
|
|
|
AMP MTCRPL W/FINGER/THUMB W/WO INTEROSS TRANSFER
|
Professional
|
Both
|
$547.00
|
|
|
Service Code
|
HCPCS 26910 80
|
| Min. Negotiated Rate |
$410.25 |
| Max. Negotiated Rate |
$547.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$536.06
|
| Rate for Payer: Beech Street Commercial |
$519.65
|
| Rate for Payer: Cash Price |
$382.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$530.59
|
| Rate for Payer: Cigna of WY Commercial |
$536.06
|
| Rate for Payer: First Choice Health Commercial |
$492.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$519.65
|
| Rate for Payer: HealthUtah PPO |
$547.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$530.59
|
| Rate for Payer: One Health Plan of WY PPO |
$536.06
|
| Rate for Payer: PacificSource Commercial |
$492.30
|
| Rate for Payer: PHCS PPO |
$519.65
|
| Rate for Payer: Three Rivers PPO |
$410.25
|
| Rate for Payer: United Healthcare Commercial |
$519.65
|
| Rate for Payer: WINHealth Partners Commercial |
$464.95
|
|
|
AMP MTCRPL W/FINGER/THUMB W/WO INTEROSS TRANSFER
|
Professional
|
Both
|
$2,145.00
|
|
|
Service Code
|
HCPCS 26910
|
| Min. Negotiated Rate |
$633.28 |
| Max. Negotiated Rate |
$2,145.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,102.10
|
| Rate for Payer: Aetna of WY Medicare |
$745.04
|
| Rate for Payer: Beech Street Commercial |
$2,037.75
|
| Rate for Payer: Cash Price |
$1,501.50
|
| Rate for Payer: Cash Price |
$1,501.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,080.65
|
| Rate for Payer: Cigna of WY Commercial |
$2,102.10
|
| Rate for Payer: First Choice Health Commercial |
$1,930.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,037.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$745.04
|
| Rate for Payer: HealthUtah PPO |
$2,145.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,080.65
|
| Rate for Payer: Multiplan Medicare/VA |
$633.28
|
| Rate for Payer: One Health Plan of WY PPO |
$2,102.10
|
| Rate for Payer: PacificSource Commercial |
$1,930.50
|
| Rate for Payer: PHCS PPO |
$2,037.75
|
| Rate for Payer: Three Rivers PPO |
$1,608.75
|
| Rate for Payer: TriWest Veterans Administration |
$745.04
|
| Rate for Payer: United Healthcare Commercial |
$2,037.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,823.25
|
|
|
AMPUTATION FOOT MIDTARSAL
|
Professional
|
Both
|
$2,254.00
|
|
|
Service Code
|
HCPCS 28800
|
| Min. Negotiated Rate |
$434.79 |
| Max. Negotiated Rate |
$2,254.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,208.92
|
| Rate for Payer: Aetna of WY Medicare |
$511.52
|
| Rate for Payer: Beech Street Commercial |
$2,141.30
|
| Rate for Payer: Cash Price |
$1,577.80
|
| Rate for Payer: Cash Price |
$1,577.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,186.38
|
| Rate for Payer: Cigna of WY Commercial |
$2,208.92
|
| Rate for Payer: First Choice Health Commercial |
$2,028.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,141.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$511.52
|
| Rate for Payer: HealthUtah PPO |
$2,254.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,186.38
|
| Rate for Payer: Multiplan Medicare/VA |
$434.79
|
| Rate for Payer: One Health Plan of WY PPO |
$2,208.92
|
| Rate for Payer: PacificSource Commercial |
$2,028.60
|
| Rate for Payer: PHCS PPO |
$2,141.30
|
| Rate for Payer: Three Rivers PPO |
$1,690.50
|
| Rate for Payer: TriWest Veterans Administration |
$511.52
|
| Rate for Payer: United Healthcare Commercial |
$2,141.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,915.90
|
|
|
AMPUTATION FOOT TRANSMETARSAL
|
Professional
|
Both
|
$1,711.00
|
|
|
Service Code
|
HCPCS 28805 80
|
| Min. Negotiated Rate |
$1,283.25 |
| Max. Negotiated Rate |
$1,711.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,676.78
|
| Rate for Payer: Beech Street Commercial |
$1,625.45
|
| Rate for Payer: Cash Price |
$1,197.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,659.67
|
| Rate for Payer: Cigna of WY Commercial |
$1,676.78
|
| Rate for Payer: First Choice Health Commercial |
$1,539.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,625.45
|
| Rate for Payer: HealthUtah PPO |
$1,711.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,659.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,676.78
|
| Rate for Payer: PacificSource Commercial |
$1,539.90
|
| Rate for Payer: PHCS PPO |
$1,625.45
|
| Rate for Payer: Three Rivers PPO |
$1,283.25
|
| Rate for Payer: United Healthcare Commercial |
$1,625.45
|
| Rate for Payer: WINHealth Partners Commercial |
$1,454.35
|
|
|
AMPUTATION FOOT TRANSMETARSAL
|
Professional
|
Both
|
$8,545.00
|
|
|
Service Code
|
HCPCS 28805
|
| Min. Negotiated Rate |
$577.67 |
| Max. Negotiated Rate |
$8,545.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,374.10
|
| Rate for Payer: Aetna of WY Medicare |
$679.61
|
| Rate for Payer: Beech Street Commercial |
$8,117.75
|
| Rate for Payer: Cash Price |
$5,981.50
|
| Rate for Payer: Cash Price |
$5,981.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,288.65
|
| Rate for Payer: Cigna of WY Commercial |
$8,374.10
|
| Rate for Payer: First Choice Health Commercial |
$7,690.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,117.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$679.61
|
| Rate for Payer: HealthUtah PPO |
$8,545.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,288.65
|
| Rate for Payer: Multiplan Medicare/VA |
$577.67
|
| Rate for Payer: One Health Plan of WY PPO |
$8,374.10
|
| Rate for Payer: PacificSource Commercial |
$7,690.50
|
| Rate for Payer: PHCS PPO |
$8,117.75
|
| Rate for Payer: Three Rivers PPO |
$6,408.75
|
| Rate for Payer: TriWest Veterans Administration |
$679.61
|
| Rate for Payer: United Healthcare Commercial |
$8,117.75
|
| Rate for Payer: WINHealth Partners Commercial |
$7,263.25
|
|
|
AMPUTATION FOOT TRANSMETARSAL
|
Professional
|
Both
|
$1,711.00
|
|
|
Service Code
|
HCPCS 28805 AS
|
| Min. Negotiated Rate |
$1,283.25 |
| Max. Negotiated Rate |
$1,711.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,676.78
|
| Rate for Payer: Beech Street Commercial |
$1,625.45
|
| Rate for Payer: Cash Price |
$1,197.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,659.67
|
| Rate for Payer: Cigna of WY Commercial |
$1,676.78
|
| Rate for Payer: First Choice Health Commercial |
$1,539.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,625.45
|
| Rate for Payer: HealthUtah PPO |
$1,711.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,659.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,676.78
|
| Rate for Payer: PacificSource Commercial |
$1,539.90
|
| Rate for Payer: PHCS PPO |
$1,625.45
|
| Rate for Payer: Three Rivers PPO |
$1,283.25
|
| Rate for Payer: United Healthcare Commercial |
$1,625.45
|
| Rate for Payer: WINHealth Partners Commercial |
$1,454.35
|
|
|
AMPUTATION LEG THROUGH TIBIA&FIBULA
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
HCPCS 27880 80
|
| Min. Negotiated Rate |
$720.44 |
| Max. Negotiated Rate |
$1,559.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,527.82
|
| Rate for Payer: Beech Street Commercial |
$1,481.05
|
| Rate for Payer: Cash Price |
$1,091.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,512.23
|
| Rate for Payer: Cigna of WY Commercial |
$1,527.82
|
| Rate for Payer: First Choice Health Commercial |
$1,403.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,481.05
|
| Rate for Payer: HealthUtah PPO |
$1,559.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,512.23
|
| Rate for Payer: One Health Plan of WY PPO |
$1,527.82
|
| Rate for Payer: PacificSource Commercial |
$1,403.10
|
| Rate for Payer: PHCS PPO |
$1,481.05
|
| Rate for Payer: Three Rivers PPO |
$1,169.25
|
| Rate for Payer: United Healthcare Commercial |
$1,481.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,325.15
|
|
|
AMPUTATION LEG THROUGH TIBIA&FIBULA
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
HCPCS 27880
|
| Min. Negotiated Rate |
$720.44 |
| Max. Negotiated Rate |
$1,559.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,527.82
|
| Rate for Payer: Aetna of WY Medicare |
$847.58
|
| Rate for Payer: Beech Street Commercial |
$1,481.05
|
| Rate for Payer: Cash Price |
$1,091.30
|
| Rate for Payer: Cash Price |
$1,091.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,512.23
|
| Rate for Payer: Cigna of WY Commercial |
$1,527.82
|
| Rate for Payer: First Choice Health Commercial |
$1,403.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,481.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$847.58
|
| Rate for Payer: HealthUtah PPO |
$1,559.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,512.23
|
| Rate for Payer: Multiplan Medicare/VA |
$720.44
|
| Rate for Payer: One Health Plan of WY PPO |
$1,527.82
|
| Rate for Payer: PacificSource Commercial |
$1,403.10
|
| Rate for Payer: PHCS PPO |
$1,481.05
|
| Rate for Payer: Three Rivers PPO |
$1,169.25
|
| Rate for Payer: TriWest Veterans Administration |
$847.58
|
| Rate for Payer: United Healthcare Commercial |
$1,481.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,325.15
|
|
|
AMPUTATION LEG THROUGH TIBIA&FIBULA
|
Professional
|
Both
|
$1,559.00
|
|
|
Service Code
|
HCPCS 27880 AS
|
| Min. Negotiated Rate |
$720.44 |
| Max. Negotiated Rate |
$1,559.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,527.82
|
| Rate for Payer: Beech Street Commercial |
$1,481.05
|
| Rate for Payer: Cash Price |
$1,091.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,512.23
|
| Rate for Payer: Cigna of WY Commercial |
$1,527.82
|
| Rate for Payer: First Choice Health Commercial |
$1,403.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,481.05
|
| Rate for Payer: HealthUtah PPO |
$1,559.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,512.23
|
| Rate for Payer: One Health Plan of WY PPO |
$1,527.82
|
| Rate for Payer: PacificSource Commercial |
$1,403.10
|
| Rate for Payer: PHCS PPO |
$1,481.05
|
| Rate for Payer: Three Rivers PPO |
$1,169.25
|
| Rate for Payer: United Healthcare Commercial |
$1,481.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,325.15
|
|
|
AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR
|
Professional
|
Both
|
$1,019.00
|
|
|
Service Code
|
HCPCS 27882
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$1,019.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$998.62
|
| Rate for Payer: Aetna of WY Medicare |
$558.99
|
| Rate for Payer: Beech Street Commercial |
$968.05
|
| Rate for Payer: Cash Price |
$713.30
|
| Rate for Payer: Cash Price |
$713.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$988.43
|
| Rate for Payer: Cigna of WY Commercial |
$998.62
|
| Rate for Payer: First Choice Health Commercial |
$917.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$968.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$558.99
|
| Rate for Payer: HealthUtah PPO |
$1,019.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$988.43
|
| Rate for Payer: Multiplan Medicare/VA |
$475.14
|
| Rate for Payer: One Health Plan of WY PPO |
$998.62
|
| Rate for Payer: PacificSource Commercial |
$917.10
|
| Rate for Payer: PHCS PPO |
$968.05
|
| Rate for Payer: Three Rivers PPO |
$764.25
|
| Rate for Payer: TriWest Veterans Administration |
$558.99
|
| Rate for Payer: United Healthcare Commercial |
$968.05
|
| Rate for Payer: WINHealth Partners Commercial |
$866.15
|
|
|
AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR
|
Professional
|
Both
|
$1,019.00
|
|
|
Service Code
|
HCPCS 27882 80
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$1,019.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$998.62
|
| Rate for Payer: Beech Street Commercial |
$968.05
|
| Rate for Payer: Cash Price |
$713.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$988.43
|
| Rate for Payer: Cigna of WY Commercial |
$998.62
|
| Rate for Payer: First Choice Health Commercial |
$917.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$968.05
|
| Rate for Payer: HealthUtah PPO |
$1,019.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$988.43
|
| Rate for Payer: One Health Plan of WY PPO |
$998.62
|
| Rate for Payer: PacificSource Commercial |
$917.10
|
| Rate for Payer: PHCS PPO |
$968.05
|
| Rate for Payer: Three Rivers PPO |
$764.25
|
| Rate for Payer: United Healthcare Commercial |
$968.05
|
| Rate for Payer: WINHealth Partners Commercial |
$866.15
|
|
|
AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR
|
Professional
|
Both
|
$1,019.00
|
|
|
Service Code
|
HCPCS 27882 AS
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$1,019.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$998.62
|
| Rate for Payer: Beech Street Commercial |
$968.05
|
| Rate for Payer: Cash Price |
$713.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$988.43
|
| Rate for Payer: Cigna of WY Commercial |
$998.62
|
| Rate for Payer: First Choice Health Commercial |
$917.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$968.05
|
| Rate for Payer: HealthUtah PPO |
$1,019.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$988.43
|
| Rate for Payer: One Health Plan of WY PPO |
$998.62
|
| Rate for Payer: PacificSource Commercial |
$917.10
|
| Rate for Payer: PHCS PPO |
$968.05
|
| Rate for Payer: Three Rivers PPO |
$764.25
|
| Rate for Payer: United Healthcare Commercial |
$968.05
|
| Rate for Payer: WINHealth Partners Commercial |
$866.15
|
|
|
AMPUTATION METATARSAL W/TOE SINGLE
|
Professional
|
Both
|
$3,008.00
|
|
|
Service Code
|
HCPCS 28810 80
|
| Min. Negotiated Rate |
$2,256.00 |
| Max. Negotiated Rate |
$3,008.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,947.84
|
| Rate for Payer: Beech Street Commercial |
$2,857.60
|
| Rate for Payer: Cash Price |
$2,105.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,917.76
|
| Rate for Payer: Cigna of WY Commercial |
$2,947.84
|
| Rate for Payer: First Choice Health Commercial |
$2,707.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,857.60
|
| Rate for Payer: HealthUtah PPO |
$3,008.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,917.76
|
| Rate for Payer: One Health Plan of WY PPO |
$2,947.84
|
| Rate for Payer: PacificSource Commercial |
$2,707.20
|
| Rate for Payer: PHCS PPO |
$2,857.60
|
| Rate for Payer: Three Rivers PPO |
$2,256.00
|
| Rate for Payer: United Healthcare Commercial |
$2,857.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,556.80
|
|
|
AMPUTATION METATARSAL W/TOE SINGLE
|
Professional
|
Both
|
$6,017.00
|
|
|
Service Code
|
HCPCS 28810 AS
|
| Min. Negotiated Rate |
$347.40 |
| Max. Negotiated Rate |
$6,017.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,896.66
|
| Rate for Payer: Beech Street Commercial |
$5,716.15
|
| Rate for Payer: Cash Price |
$4,211.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,836.49
|
| Rate for Payer: Cigna of WY Commercial |
$5,896.66
|
| Rate for Payer: First Choice Health Commercial |
$5,415.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,716.15
|
| Rate for Payer: HealthUtah PPO |
$6,017.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,836.49
|
| Rate for Payer: One Health Plan of WY PPO |
$5,896.66
|
| Rate for Payer: PacificSource Commercial |
$5,415.30
|
| Rate for Payer: PHCS PPO |
$5,716.15
|
| Rate for Payer: Three Rivers PPO |
$4,512.75
|
| Rate for Payer: United Healthcare Commercial |
$5,716.15
|
| Rate for Payer: WINHealth Partners Commercial |
$5,114.45
|
|
|
AMPUTATION METATARSAL W/TOE SINGLE
|
Professional
|
Both
|
$6,017.00
|
|
|
Service Code
|
HCPCS 28810
|
| Min. Negotiated Rate |
$347.40 |
| Max. Negotiated Rate |
$6,017.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,896.66
|
| Rate for Payer: Aetna of WY Medicare |
$408.70
|
| Rate for Payer: Beech Street Commercial |
$5,716.15
|
| Rate for Payer: Cash Price |
$4,211.90
|
| Rate for Payer: Cash Price |
$4,211.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,836.49
|
| Rate for Payer: Cigna of WY Commercial |
$5,896.66
|
| Rate for Payer: First Choice Health Commercial |
$5,415.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,716.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$408.70
|
| Rate for Payer: HealthUtah PPO |
$6,017.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,836.49
|
| Rate for Payer: Multiplan Medicare/VA |
$347.40
|
| Rate for Payer: One Health Plan of WY PPO |
$5,896.66
|
| Rate for Payer: PacificSource Commercial |
$5,415.30
|
| Rate for Payer: PHCS PPO |
$5,716.15
|
| Rate for Payer: Three Rivers PPO |
$4,512.75
|
| Rate for Payer: TriWest Veterans Administration |
$408.70
|
| Rate for Payer: United Healthcare Commercial |
$5,716.15
|
| Rate for Payer: WINHealth Partners Commercial |
$5,114.45
|
|
|
AMPUTATION TOE INTERPHALANGEAL JOINT
|
Professional
|
Both
|
$2,570.00
|
|
|
Service Code
|
HCPCS 28825 AS
|
| Min. Negotiated Rate |
$1,927.50 |
| Max. Negotiated Rate |
$2,570.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,518.60
|
| Rate for Payer: Beech Street Commercial |
$2,441.50
|
| Rate for Payer: Cash Price |
$1,799.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,492.90
|
| Rate for Payer: Cigna of WY Commercial |
$2,518.60
|
| Rate for Payer: First Choice Health Commercial |
$2,313.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,441.50
|
| Rate for Payer: HealthUtah PPO |
$2,570.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,492.90
|
| Rate for Payer: One Health Plan of WY PPO |
$2,518.60
|
| Rate for Payer: PacificSource Commercial |
$2,313.00
|
| Rate for Payer: PHCS PPO |
$2,441.50
|
| Rate for Payer: Three Rivers PPO |
$1,927.50
|
| Rate for Payer: United Healthcare Commercial |
$2,441.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,184.50
|
|
|
AMPUTATION TOE INTERPHALANGEAL JOINT
|
Professional
|
Both
|
$3,526.00
|
|
|
Service Code
|
HCPCS 28825
|
| Min. Negotiated Rate |
$140.99 |
| Max. Negotiated Rate |
$3,526.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,455.48
|
| Rate for Payer: Aetna of WY Medicare |
$165.87
|
| Rate for Payer: Beech Street Commercial |
$3,349.70
|
| Rate for Payer: Cash Price |
$2,468.20
|
| Rate for Payer: Cash Price |
$2,468.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,420.22
|
| Rate for Payer: Cigna of WY Commercial |
$3,455.48
|
| Rate for Payer: First Choice Health Commercial |
$3,173.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,349.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.87
|
| Rate for Payer: HealthUtah PPO |
$3,526.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,420.22
|
| Rate for Payer: Multiplan Medicare/VA |
$140.99
|
| Rate for Payer: One Health Plan of WY PPO |
$3,455.48
|
| Rate for Payer: PacificSource Commercial |
$3,173.40
|
| Rate for Payer: PHCS PPO |
$3,349.70
|
| Rate for Payer: Three Rivers PPO |
$2,644.50
|
| Rate for Payer: TriWest Veterans Administration |
$165.87
|
| Rate for Payer: United Healthcare Commercial |
$3,349.70
|
| Rate for Payer: WINHealth Partners Commercial |
$2,997.10
|
|
|
AMPUTATION TOE METATARSOPHALANGEAL JOINT
|
Professional
|
Both
|
$342.00
|
|
|
Service Code
|
HCPCS 28820 80
|
| Min. Negotiated Rate |
$256.50 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$335.16
|
| Rate for Payer: Beech Street Commercial |
$324.90
|
| Rate for Payer: Cash Price |
$239.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$331.74
|
| Rate for Payer: Cigna of WY Commercial |
$335.16
|
| Rate for Payer: First Choice Health Commercial |
$307.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$324.90
|
| Rate for Payer: HealthUtah PPO |
$342.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$331.74
|
| Rate for Payer: One Health Plan of WY PPO |
$335.16
|
| Rate for Payer: PacificSource Commercial |
$307.80
|
| Rate for Payer: PHCS PPO |
$324.90
|
| Rate for Payer: Three Rivers PPO |
$256.50
|
| Rate for Payer: United Healthcare Commercial |
$324.90
|
| Rate for Payer: WINHealth Partners Commercial |
$290.70
|
|
|
AMPUTATION TOE METATARSOPHALANGEAL JOINT
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
HCPCS 28820 AS
|
| Min. Negotiated Rate |
$210.75 |
| Max. Negotiated Rate |
$281.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$275.38
|
| Rate for Payer: Beech Street Commercial |
$266.95
|
| Rate for Payer: Cash Price |
$196.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$272.57
|
| Rate for Payer: Cigna of WY Commercial |
$275.38
|
| Rate for Payer: First Choice Health Commercial |
$252.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$266.95
|
| Rate for Payer: HealthUtah PPO |
$281.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$272.57
|
| Rate for Payer: One Health Plan of WY PPO |
$275.38
|
| Rate for Payer: PacificSource Commercial |
$252.90
|
| Rate for Payer: PHCS PPO |
$266.95
|
| Rate for Payer: Three Rivers PPO |
$210.75
|
| Rate for Payer: United Healthcare Commercial |
$266.95
|
| Rate for Payer: WINHealth Partners Commercial |
$238.85
|
|
|
AMPUTATION TOE METATARSOPHALANGEAL JOINT
|
Professional
|
Both
|
$1,735.00
|
|
|
Service Code
|
HCPCS 28820
|
| Min. Negotiated Rate |
$144.53 |
| Max. Negotiated Rate |
$1,735.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,700.30
|
| Rate for Payer: Aetna of WY Medicare |
$170.04
|
| Rate for Payer: Beech Street Commercial |
$1,648.25
|
| Rate for Payer: Cash Price |
$1,214.50
|
| Rate for Payer: Cash Price |
$1,214.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,682.95
|
| Rate for Payer: Cigna of WY Commercial |
$1,700.30
|
| Rate for Payer: First Choice Health Commercial |
$1,561.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,648.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$170.04
|
| Rate for Payer: HealthUtah PPO |
$1,735.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,682.95
|
| Rate for Payer: Multiplan Medicare/VA |
$144.53
|
| Rate for Payer: One Health Plan of WY PPO |
$1,700.30
|
| Rate for Payer: PacificSource Commercial |
$1,561.50
|
| Rate for Payer: PHCS PPO |
$1,648.25
|
| Rate for Payer: Three Rivers PPO |
$1,301.25
|
| Rate for Payer: TriWest Veterans Administration |
$170.04
|
| Rate for Payer: United Healthcare Commercial |
$1,648.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,474.75
|
|
